Exclusive Breastfeeding Reduces Risk of Enterocolitis by Modulating the Enteric Microbiome in Patients with Hirschsprung's Disease

Abstract

Background: Hirschsprung-associated enterocolitis (HAEC) is the leading cause of mortality in Hirschsprung's disease (HSCR) patients. We aimed to examine the association between exclusive breastfeeding and risk of HAEC as well as the underlying mechanisms. Methods: In a hospital-based cohort study of 253 HSCR patients, we examined the association between exclusive breastfeeding and risk of HAEC by log-binomial regression. Using enteric tissue samples collected at surgery, we further conducted a prospective nested case-control study of 25 postoperative HAEC cases and 50 HSCR controls. We characterized the enteric microbiome by 16S rRNA gene sequencing and measured lipopolysaccharide by an enzyme-linked immunosorbent assay. Relative abundance of Gram-negative bacteria and LPS concentrations were compared between groups: (1) postoperative HAEC cases and controls; (2) HSCR patients with and without exclusive breastfeeding, using Wilcoxon rank-sum test. Stepwise random forest classification was used to identify an enteric microbiome signature to predict postoperative HAEC occurrence. Findings: Exclusive breastfeeding was associated with lower risk of overall and postoperative HAEC, with an adjusted RR of 0.61 (95% CI, 0.44-0.85; P=0.003) and 0.51 (95% CI, 0.24-1.08; P=0.08), respectively. Exclusive breastfeeding contributed to an enteric microbiome characterized by lower abundance of Gram-negative bacteria (particularly Enterobacteriaceae) and lower lipopolysaccharide concentrations, which was associated with lower occurrence of postoperative HAEC. In addition, we identified a microbiome signature that predicted postoperative HAEC occurrence with ~85% accuracy. Interpretation: Exclusive breastfeeding reduces risk of HAEC through modulation of the enteric microbiome. Funding Statement: This work was supported by the National Natural Science Foundation of China (NSFC 81570467). Declaration of Interests: Authors declare that they have no competing interests. Ethics Approval Statement: The study was approved by the Medicine Ethics Committee at Children’s Hospital of Nanjing Medical University and the Human Subjects Committee at the Lawrence Berkeley National Laboratory, and all participants provided informed consent.